Friday 9th December, 2022 Seminars

It has been 60 years since the ground-breaking report 'Smoking and Health' was published by the Royal College of Physicians, at a time when smoking prevalence was close to 70% for men and 40% for women. Whilst that report laid the foundations of tobacco control and great progress has been made in reducing smoking prevalence, there is much more to do if we are to prevent the annual global tobacco related death toll of 8 million people. The COVID-19 pandemic illustrated the collaboration and effectiveness with which the global scientific, public health and medical communities can come together to tackle a public health emergency and it is in this same spirit that the tobacco control community must overcome the devastation that tobacco leaves in its wake

The report is the last in a series of independent reviews commissioned by the Office for Health & Disparities (formerly Public Health England). The purpose of the reports is to inform government and policy makers about prevalence and characteristics of vaping among adults and young people in England and each year we cover at least one additional topic in depth. This year’s report included systematic reviews on the health risks of vaping compared with smoking, and vaping compared with non-use, as well as harm perceptions about vaping and smoking. It also puts the findings in the context of the series of evidence reviews since 2015. This presentation will provide an overview of the report; it will explain how we came to the conclusions that vaping poses a small fraction of the risk of smoking but is not risk free. The talk will also discuss some of the implications of the review findings.

Flavours in e-cigarettes exert multiple points of influence across a range of health-relevant issues, from youth initiation to discontinuation of tobacco use among adults. Flavours also continue to be an important consideration in regulatory approaches to vaping products. National and subnational jurisdictions around the world have various regulatory authorities to address flavoured e-cigarettes in a number of ways, ranging from packaging and labelling rules, to restricting the use of specific flavourings via product standards, and as far as banning characterising flavours in all vaping products. This presentation will bring together timely multi-disciplinary research findings on how flavours in e-cigarettes impacts product appeal (especially to youth), user behaviour (including initiation of product use among non-users and transitions from smoking to vaping among current smokers), chemistry and toxicity of flavoured products, and short/long-term health outcomes

Cigarette smoking is a significant public health concern, despite stringent regulation. Switching smokers to a less harmful product would therefore mitigate some of this harm. Few alternatives have proven attractive to smokers. Electronic nicotine delivery systems (ENDS or e-cigarettes) deliver nicotine in a way similar to that of conventional cigarettes and hence potentially provide an acceptable alternative. The Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) was asked to review the relative toxicological risks from ENDS, compared to smoking conventional cigarettes, and the absolute risks from use of ENDS. ENDS are substantially less harmful than conventional cigarettes, although the difference varies with the health effect. There is little evidence that short to medium term use of ENDS causes major harm, but the effects of long-term use are uncertain, though still likely to be less than those of conventional cigarettes. Use of ENDS by non-smokers is potentially associated with adverse health effects to which they would not otherwise have been subject. This information should not be considered in isolation, but in the wider context of the public health consequences of cigarette smoking.

The Cochrane review of e-cigarettes for quitting smoking was updated this year, and new studies have important implications for certainty of key outcomes. A companion piece, also recently out, investigates biomarkers of potential harm in people who smoke who are given e-cigarettes, but do not successfully quit (dual users). This session will cover key findings from both pieces of work, and also consider the mixed standards used when describing the ‘certainty’ of evidence about the benefits and harms of e-cigarettes.

E-cigarettes have emerged as a more popular quitting aid among pregnant smokers than traditional NRT. Such use of e-cigarettes has been condoned in the UK but advised against in the US.  In this session, Prof Hajek will look at some of the evidence regarding nicotine effects in pregnancy, specifically the existing human data, as opposed to animal studies.  He will also present the data from a large, randomised trial that compared smoking cessation and pregnancy outcomes in pregnant smokers allocated to e-cigarettes or NRT.  Finally, the session will discuss whether switching from smoking to e-cigarettes poses any risks to pregnancy outcomes and the significance of the findings for clinicians, service providers and pregnant smokers.

• Given the known harms of smoking, how do we communicate uncertainty?
• What health harms are we anticipating in the future from long term use of e-cigarettes?
• If we remove flavours from e-cigarettes, would there be a net public health gain?
• Is there a toxicological basis for excluding flavours?
• What are the health effects of nicotine use – harms and/or benefits?

This talk will look at what were the hopes and fears for the public health impact of e-cigarettes to 10 years ago, how far these have come to pass, and what we might expect in 10 years’ time, depending on policies adopted and technological change. It will take an international perspective, examining the landscape in countries where good population-level data are available. Neither the hopes nor the fears have yet been fully borne out. E-cigarettes appear to have contributed to reductions in smoking prevalence in countries with more permissive regulatory regimes but as yet the contribution has not been as great as some had hoped. Credible evidence has emerged that e-cigarettes are not harmless but the degree of harm appears likely to be an order of magnitude less than from cigarette smoking. At a population level, evidence has not supported the hypothesis that e-cigarettes would be a gateway to tobacco use among young people. There is evidence that some young people who would never have smoked have used e-cigarettes, but to date this use appears to be primarily occasional. E-cigarette technology continues to advance in terms of creating devices that deliver nicotine efficiently in a palatable form but there are challenges regarding their impact on the environment. The topic of e-cigarettes has become, if anything, more divisive among public health experts, with evidence often being distorted or misrepresented and personal attacks being launched both ways across the divide. It remains possible that with the right kind of regulation, e-cigarettes could contribute further to a reduction in tobacco-related harm as part of a comprehensive tobacco control policy. This will be more likely if protagonists sign up to a set of ethical standards regarding the conduct and interpretation of science and work collaboratively to the development of evidence-based policies.

Until recently, disposable e-cigarettes were considered of historic interest, made obsolete by rechargeable devices with better nicotine delivery. For instance, just 1 in 20 British vapers chose disposable e-cigarettes as their main device from 2016 to 2020. Yet over the past two years, we have witnessed the market become flooded with new disposable e-cigarettes that are cheap, convenient, and good at delivering nicotine. There is mounting concern that these modern disposable devices may be especially appealing to children and younger adults. Recent data from Great Britain show that the popularity of disposable e-cigarettes grew rapidly between 2021 and 2022, particularly among young people. Now more than half of 18-year-old vapers mainly use disposable products. The public health impact of this growth will depend on who uses disposable e-cigarettes: people who would otherwise smoke cigarettes, vape other types of e-cigarettes, or avoid nicotine entirely. Harry will examine the causes and consequences of this rise in disposable vaping, in the context of the changing prevalence of vaping and cigarette smoking.

It’s well-established that vaping helps some people quit smoking, but concerns over the unknown long-term health effects and rise in youth disposable vaping, has seen greater demand for tighter restrictions. But policy decisions have consequences and not all of them are intended.  In this session, Dr Jasmine Khouja will present a recent study that asked smokers and vapers how they would feel about flavours being banned in the UK. Study participants also made many unprompted suggestions for alternative policies with common themes that should be explored further.

Public health professionals in England recognise that vape products can play a useful role in helping smokers cut down or quit, but a recent rise in young people’s use of disposable devices has led to calls for increased regulation. This presentation will explore the rise of disposables from the point of view of ordinary smokers and quitters from routine and manual backgrounds. Based on eight months of fieldwork across the UK, fifty interviews with vapers aged 16+ and ten interviews with vape retailers, this session will explore the reality versus the rhetoric of disposable use. Questions considered will include: what potential might disposables have to address health inequalities linked to smoking? And which young people are really being considered in the pressure for regulatory action?

Tobacco smoking is a leading cause of poor health outcomes and inequalities amongst people experiencing extensive health and social needs (e.g., homelessness, substance dependencies). An erroneous perception exists that individuals living with such needs do not engage in health services and as such, are described as 'hard to reach', 'disengaged' or 'uninterested'. This talk highlights why these descriptors are not grounded in evidence.  It will also highlight how we can maximise existing opportunities to offer cessation support, including how tobacco harm reduction approaches are central to offering support and helping to reduce inequalities and long held misperceptions.

To paraphrase the Cheshire Cat in Alice in Wonderland, "if you don't know where you are going, any road will take you there". Are we thrashing about doing the wrong things in public health and tobacco control because we have wrong or outdated models of the phenomena we are dealing with? Many professionally engaged in tobacco control leadership roles had their formative experience in the heat of the tobacco wars. But is that experience a help or a hindrance now?  How should we understand the drug nicotine, nicotine addiction, the motivation of consumers, youth risk behaviours, the tobacco industry, and the intense opposition to tobacco harm reduction? This presentation goes in search of reliable foundations to underpin our approach to nicotine and public health.

• Disposables are cheap, accessible, and popular – is it time to legislate?
• Are disposables marketed to kids and if so, how and by whom?
• Should we legislate to ban disposables or flavours – both or neither?
• Is this a regulation or enforcement challenge?
• What evidence do we have that kids or adults respond to risk messaging?

On the last day of September 2022 Public Health England closed its doors. On the first day of October the Office of Health Improvement started work in earnest. Some may have anticipated a slowing of the pace on e-cigarettes but by the end of the month Secretary of State for Health Sajid Javid was talking of a “vaping revolution.” By the time of OHID’s first birthday its achievements included publication of Khan review and the milestone report Nicotine Vaping in England 2022. Rosanna will look back on OHID’s first year and forward at the emerging issues and opportunities with all the clarity that circumstances allow.

Policies to shift the market for nicotine from cigarettes to non-combustibles (as, for example, the mooted FDA proposal to reduce the absolute bioavailability of nicotine from cigarettes to non-reinforcing levels) have as an essential component the development of consumer-acceptable alternative novel nicotine products. Regulators may seek to set limits for the nicotine dose available from non-combustibles at their peril, as this may seriously constrain the chances of developing successful alternatives to the cigarette.

This presentation will consider data from major national surveys in the USA (National Health & Nutrition Examination Survey) and UK (Health Survey for England) to examine how patterns of nicotine intake from cigarettes can help guide the specification for new products.  Key themes concern the overriding importance of consumer behaviour, as opposed to product characteristics in determining dose; extreme elasticity of the cigarette in dose titration and response to secular market change, as well as marked variations in preferred dose across ethnic and demographic groups.

A medicinally-authorized e-cigarette has been a topic of discussion since before the first Summit in 2013.  There were those who argued that only medicinally-licensed e-cigarettes should be on the market, while others believed that a medicinal-only marketplace would be accessible only for the big tobacco companies – who arguably had the least incentive to lead a revolution against combustible cigarettes.  MHRA has taken multiple steps to encourage the filing of a medicinal application for an e-cigarette, culminating in late 2021 in the publication of an updated guidance document, announced by the MHRA in a Press Release entitled “E-cigarettes could be prescribed on the NHS in world first.”  The recent Kahn Review has also recommended the addition of medicinally-licensed e-cigarettes, as a vehicle for increasing general practitioner and other healthcare provider confidence in vaping.  Is a medicinally-licensed e-cigarette possible?  Is it, in fact, only the province of big tobacco?  David Graham provides the perspective of an independent company that has successfully navigated FDA’s PMTA process, addressing the achievability of a UK medicinal license and drawing parallels and distinctions between a UK medicinal application and the US PMTA.

Back in 2013, the disposable e-cigarette was a product type that many of us thought to be in its early death throes.  Advocates and the independent industry alike were certain that it would all be about refillable, reusable and rechargeable open systems from there on in.  We can track the re-birth, understanding the market forces that have carried the growth, examining the spectrum of ethical and moral standards behind active marketing campaigns, and looking in detail at what we can objectively state about “new consumers” of disposable vapour products. We can also compare these newer entrants to vaping with our sector’s existing customers before the arrival of the latest disposable vapes. In short, what are brightly coloured and intensely flavoured new vapes really doing to the overall nicotine market: vaped, smoked or “other”?

From an industry viewpoint, this leads very directly to regulation. In November 2013 the discussion was focused on Europe, and the wheel has since then turned full circle from TPD2 to TPD3. With 8 years’ hindsight, what were the strengths and weaknesses of Directive 2014/40/EU’s impact on the diverse e-cigarette markets that it touched? How much of the enduring diversity in those markets is due to variation in regulations? Is the UK’s advanced position in reducing smoking through a nicotine harm-reduction approach engineered, “nudged,” or just a happy accident? How is it that the French, German and UK vape markets have so many clear differences? Finally, as an industry sector, what pleas to policy makers and regulators are in the best interests of our customers, present and future?

Between 2020 and 2022 the Belgian Superior Health Council undertook an extensive review and consultation on e-cigarettes with a view to providing updated guidance and advice for tobacco policy.  It took 2 years to arrive at this advice and was the result of multi stakeholder engagement from across tobacco control communities, scientific disciplines as toxicology, pneumology, oncology, psychiatry, psychology, sociology ..., points of interest such as health promotion and health inequality, and vigorous scientific review. The final advice has been a compromise which highlights the need to focus - with equal attention - on both opportunities and risks.  In this session Stefaan will explore the process and challenges of creating a public health consensus amidst an evolving phenomenon which has highlighted the distinct divides between traditional tobacco control sentiment and harm reduction proponents.  Although there remains some controversy, the advice has provided a framework for developing a risk-based policy and recognises the role that harm reduction can play within public health and what this means for the current framework and approach of smoking and smoking cessation.

Smoking kills 6,000 people in Ireland every year and many thousands more suffer from smoking related illnesses that will eventually be a significant contributor to their early demise. The Department of Health has targeted 2037 as the year when Ireland will be smoking free. In order to reach that target it is imperative that no smoker who wants to quit encounters any barriers that might prevent them from doing so. With that in mind, there are an estimated 200,000 people using e-cigarettes, almost all of which are using them to quit smoking. This method of smoking cessation is fast growing and research shows e-cigarettes are at least twice as effective as traditional NRT. Despite these impressive statistics Ireland’s health service, the HSE, does not recommend vaping as a smoking cessation intervention on the basis there is not enough evidence of either effectiveness or safety.

Concern has been exclusively focused around adolescent e-cigarette use (about 4% of youths who vape do so in a daily or near daily manner). Plans are afoot by the Government to ban flavours as these are viewed as attractive to adolescents. This presentation examines the current legislation in Ireland around e-cigarette use and availability and takes a close look at the medical profession’s attitude towards vaping as a smoking cessation tool. It also highlights some of the media debates that have occurred between pro vaping and anti-vaping doctors. Dr Garrett will also present some case studies of smokers and their experiences in trying to quit and the advice they have received from various health professionals.

• Which problems are we primarily trying to solve – smoking or nicotine dependence?
• Has risk communication been appropriate to the scale of the problem?
• What are the greatest barriers to improving the quality of the harm reduction debate
• What role would/could a medicinal product have in reducing smoking and changing the harm reduction debate?
• What next for e-cigarettes – are disposables the last evolution and what role does regulation play?
• Has restricting nicotine levels in e-cigarettes been beneficial?

Research over the past decade has provided evidence for the potential of harm reduction from e-cigarettes, but there are considerable challenges along the path from potential to reality, of which a key component is the extent to which e-cigarettes can help smokers quit. Clinical trials have demonstrated the efficacy of e-cigarettes as a cessation aid, but ultimately, studies of the effectiveness of e-cigarettes for quitting smoking in the real world will tell us whether the potential of harm reduction is being realized. This presentation describes the conceptual model underlying the ITC Project’s longitudinal cohort studies being conducted across key countries where e-cigarettes and/or heated tobacco products hold an important presence in the tobacco/nicotine product marketplace. At the centre of the conceptual model is the individual user and his/her transitions (or lack of transitions) between products over time.  The possible causal forces that influence those transitions, among others, include those within the individual (e.g., history of smoking, dependence), those within the social environment (e.g., product use of close others, norms), product characteristics (e.g., nicotine delivery, flavours, ease of use), and policies and regulations on alternative products, and on cigarettes. The model is structurally symmetric in that policies and regulations on both cigarettes and on alternative products can have an impact on the individual and his/her transitions.  This presentation, which will review some recent ITC findings, will discuss important implications of this conceptual model for measuring and understanding the possible role of alternative nicotine products and policies on those products and on cigarettes in reducing smoking. It will also highlight important limitations in the role of policies in shaping those transitions.

Mr. Zeller will share his views on the evolution of the harm reduction debate in the United States, where for nearly 30 years he has played a central role.  He will talk about the process of achieving consensus around harm reduction and the continuum of risk in the 2005-2009 Strategic Dialogue on Tobacco Harm Reduction, which he co-led, and in the adoption of the Tobacco Control Act in 2009, which provided a mechanism for FDA review and authorization of true reduced risk products.  He will describe the current stalemate in the U.S. on issues related to tobacco harm reduction and e-cigarettes.  Finally, Mr. Zeller will close with thoughts on one potential endgame strategy focused on making combustible tobacco products minimally or nonaddictive.

Aotearoa New Zealand’s government has tabled some of the world’s most aggressive tobacco control policy with an explicit focus on smoked tobacco. Endgame legislation proposes to remove nicotine from all smoked tobacco, drastically reduce supply by 95%, and ban the sale of smoked tobacco to anyone born after January 2009. The aim being to reduce smoking rates to under 5% by 2025. The proposed smoking endgame legislation builds on recent laws regulating the sale and use of vaping products. A harm reduction approach ensures vaping is accessible to adult smokers, whilst protecting never-smokers from taking up vaping. New Zealand’s liberal approach to vaping is seen as prerequisite to highly aggressive policies that will restrict and devalue smoked tobacco. For many the smoking endgame policy represents the peak of New Zealand’s history of tobacco control leadership, for others it creates deep concerns about coercive approaches to people who smoke. This talk will outline the context for New Zealand’s endgame legislation, the role of vaping and harm reduction, and examine perspectives around what these policies might mean for public health, social justice and health equity.

The status of reduced-risk products in a smokefree society In Norway has meant that practically no one initiates cigarette smoking any longer. The prevalence of daily smoking in the age-group 16-24 years has dropped below the 2% mark. The remaining smokers are typically in their 60's. Within few decades Norway will probably be almost smokefree, thanks to previous decades of robust infrastructure for tobacco control - and to the long-time availability of a popular alternative to cigarettes; snus. Compared to cigarettes, snus is cheaper, comes in a variety of flavors, can be used indoors and correctly perceived as less risky. The majority of snus users are made up of ever-smokers and youth susceptible for smoking uptake. But as smoking declines, the reservoir of its most potential users (smokers) will shrink, and subsequently the relative share of never-smokers among snus users will increase. Faced with this prospect, the authorities have signalled that they will make snus the next target. This is the backdrop for the emerging debate on the future for low-risk nicotine products for non-therapeutic recreational use. Dr Lund will give an account of this debate - now in the process of overshadowing the debate about harm reduction (which is considered increasingly irrelevant because there will be no smoking to cure with alternative nicotine products).

The level of adolescent tobacco use ranges from around 2% to over 30% worldwide, depending on region and on the form of tobacco. As the leading cause of preventable death globally, most of the global mortality burden of tobacco use lies predominantly in ‘low to middle’ income countries (LMICs).

Overall, about a fifth of young teenagers (13–15 years) around the world are smokers. High-income countries may lower levels of adolescent tobacco use. Low and middle-income countries have contrastingly high rates of adolescent smoking, where rates in some countries can reach as high as 46% and reflect high rates of all-age smoking. Adult smoking rates generally appear to reflect adolescent smoking rates

With this fear in mind, policymakers in LMICs have made “tobacco control” a priority to mitigate effects of tobacco related morbidity and mortality, by harnessing cessation interventions techniques from high-income countries. In reality, we are only seeing an increasing number of smokers in LMIC, questioning the effectiveness of the ‘total cessation’ policy. This session reviews reasons for this failed attempt of ‘total cessation’ in LMICs, and the possible risks it possesses. One evident phenomenon is the creation of ‘hidden populations’ of smokers, who continue their smoking habit against regulations and isolate from health providers, in fear of litigation.

Is there a role for ‘tobacco harm reduction’ in the form of e-cigarettes or alternate non-combustible products over ‘total cessation’ policies? Despite evidence of its less harmful effects compared to conventional cigarettes, there has been lots of restrictions and hesitations towards ‘tobacco harm reduction’. In driving their agenda, international policies have also neglected special populations, individuals living with mental health problems, where even nicotine replacement has shown modest results.

This talk stands firm on the fundamental understand that ‘harm reduction’ initiatives respect the rights, health and safety of smokers, without compromising on ‘the right of all people to the highest standard of health’, as per WHO’s Framework Convention on Tobacco Control.

Deborah Arnott will set out how the UK government’s approach to e-cigarettes is misunderstood and overstated both by those who support and oppose the role of these products in helping bring about the end of smoking. She will make a plea for both sides to recognise that the UK government positions harm reduction in tobacco control as just one tool in the toolbox, relevant to the UK because of the phase it has reached in the tobacco epidemic. She will examine how political theory can be used to explain how the UK got to this position, and what the implications are for the future of harm reduction in other countries, regions and globally.

• Each Country has taken different approaches to fix the same problem – why is this?
• Why is harm reduction a recognised tool for many societal issues, but so controversial in tobacco control?
• We recognize and protect public health policy discussions from conflicts of interest with tobacco industry but is there a conflict of interest with extreme philanthropic funding? – should these be declared?
• Novel nicotine products come in many different forms and exist under different legislation in different countries.  Is there a case for liberalizing the nicotine market?